musculoskeletal system surgical procedures

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Transcript of musculoskeletal system surgical procedures

  • MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURESMusculoskeletal System Surgical ProceduresApril 1, 2015

    PREAMBLE

    A. Corrective splints must be corrective to qualify for a benefit as such. The corrective splint listings are not applicable to simple immobilization such as with a Jones bandage or metal finger splint following soft tissue injury.

    B. The removal of a wire or pin or other device when used for traction or external fixation (except for rigid external fixators) in the treatment of a fracture or other orthopaedic procedure is to be included in the procedural fee (unless otherwise stated in the Schedule) unless a general anaesthetic is required, in which case a fee may be claimed. Removal of devices used for internal fixation more than 30 days after insertion may be claimed for in addition to the procedural benefit.

    C. The benefit for total joint replacement also includes denervation of the joint, all tenotomies and division and repair of muscle.

    D. The benefit for obtaining a bone graft is not to be claimed in cases of pseudoarthrosis repair, fusions or for listings in which bone grafting is included.

    E. For the supervision of limb fitting and 6 months post-operative care following amputation, claim visit fees. Amputation with immediate fitting to include supervision of final limb fitting, add 40% (E586).

    Note:Reconstruction or Arthroplasty Procedures: If other procedures are claimed, same joint, same time, e.g. debridement, synovectomy, tendon release etc., the Medical Consultant will assess the surgeon's claim.

    # E554 - synovectomy requiring a minimum of 30 minutes to resect, to R236, R240, R241, R244, R281, R288, R436, R437, R438, R439, R440, R441, R443, R453, R454, R456, R479, R481, R482, R483, R485, R486, R487, R488, R491, R493, R496, R497, R498, R499, R500, R509, R510 ....................add 175.00

    Payment rules:Synovectomy codes other than E554 are not eligible for payment when rendered in addition to the codes listed above.

    FRACTURES AND DISLOCATIONS1. For fractures or dislocations requiring open or closed reduction or no reduction, the major pre-operative visit, i.e. consultation or

    appropriate assessment, may be claimed in addition to the listed benefits.

    2. OPEN REDUCTION shall mean the treatment of a fracture and/or dislocation by either closed intramedullary fixation or by an operative procedure to expose the fracture. The benefits include fixation by internal or external devices.

    3. CLOSED REDUCTION shall mean the reduction of a fracture or dislocation by non-operative methods (including traction).

    4. NO REDUCTION shall mean the treatment of a fracture or dislocation by any other method and includes the use of the initial external support other than a simple splint. No reduction, rigid immobilization, means that the device used to achieve a rigid immobilization is custom-molded and is applied by the physician. In cases involving no reduction, application of a simple splint, such as a metal splint, is not billable as rigid immobilization (visit fees only apply).

    5. The service includes all related follow-up treatment by the physician for 2 weeks from the date of treatment of the fracture or dislocation except:

    a. for the first and second post-treatment visits to a hospital in-patient;

    b. for the subsequent visit by the MRP - day of discharge (C124);

    c. for the first post-treatment visit when the patient is no longer a hospital in-patient;

    d. if additional reductions are necessary;

    e. if the patient is transferred to another surgeon; or

    f. if the patient is a paraplegic.

    [Commentary:The first and second post-treatment visits in hospital for 2 weeks from the date of treatment of the fracture or dislocation are payable at the specialty specific subsequent visit fee.]April 1, 2015 N1 Amd 12 Draft 1

  • MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURESPREAMBLE

    6. In multiple fractures or dislocations, the benefit for the major fracture or dislocation shall be 100% and the benefit for the other fractures or dislocations is 85%. When no procedural benefit is applicable, but that fracture or dislocation necessitates hospitalization or concurrent care over that demanded by the major injury, a visit benefit may be claimed in addition to other procedural benefits.

    7. For repeat reductions (closed or open) for the same fracture or dislocation, the full benefit should be claimed for the final reduction and after care; previous reductions by the same surgeon should be claimed at 85%.

    8. Emergency splinting of fractures in the emergency department should be on the basis of appropriate visit benefit, plus application of cast if appropriate.

    9. Transferred cases:

    a. When patients are transferred to a chronic or convalescent facility, additional visit benefits on a chronic care basis shall be allowed to other than the operating surgeon (and also to the surgeon after 2 weeks).

    b. When patients are transferred to another physician for after care of fractures and dislocations treated by closed or no reduction, the physician rendering the initial care should claim 75% of the listed fee and the surgeon rendering subsequent care should claim visit fees except where otherwise specified. In cases involving open reduction, the percentage should be 80% for the surgeon providing the initial care.

    c. In cases where the original physician's attempts to reduce a fracture or dislocation under general anaesthesia is unsuccessful, and the patient is referred to another physician for definitive care, the original physician should claim 75% of the listed fee.

    10. Pseudoarthrosis may be allowed as the appropriate benefit after the fracture is 4 months old.

    11. For fractures and dislocations not requiring reduction, visit fees apply unless a specific fee is listed. If the listed fee is less than the consultation, the consultation should be claimed under the fracture/dislocation fee code number.N2 April 1, 2015Amd 12 Draft 1

  • MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURESGENERAL FEES

    Asst Surg Anae

    BONE/FASCIAL/DERMIS GRAFTS

    Autogenous# E551 - separate incision.......................................................................................add 86.30# E552 - same incision ............................................................................................add 58.45# Z279 - different surgeon ................................................................................................ 193.00

    Homogenous# E553 - banked bone or bone substitutes..............................................................add 25.15

    Allograft # R200 - cadaver - per long bone, each ........................................................................... 144.80

    Note:Other donor allografts are payable at 85% of the listed excision fee.

    FIXATION# E547 - methyl methacrylate (not arthroplasty) .....................................................add 59.40# E555 - rigid external fixation (excluding casts) for closed reduction, to closed

    reduction fee .....................................................................................add 50%# E544 - cast bracing with closed reduction, to closed reduction fee..............add 40%# E569 - percutaneous pinning, to closed reduction fee .................................add 50%# E826 - percutaneous pinning, to F005, F006, F009, F013 or F016 .............add 75%

    Note:E569 is not eligible for payment with E826.

    # E590 - rigid external fixation - pseudoarthrosis ....................................................add 76.10

    Removal of internal fixation device# R267 - general anaesthetic............................................................................................ 6 158.65 6# R268 - local anaesthetic ................................................................................................ 6 54.85 6

    # R598 Removal of extensive external fixation device under general anaesthetic .............. 48.25 6

    Adjustment of circumferential external fixation # Z280 - without general anaesthetic ............................................................................... 72.35# Z281 - with general anaesthetic .................................................................................... 145.70 6

    # Z210 - Insertion traction pin - excludes fractures and dislocations ............................... 33.35

    WOUND CAREE550 - insertion of closed irrigation system during a surgical procedure for post-

    operative management .............................................................................add 63.15

    # E556 - extensive debridement of compound fractures or dislocations, to reduction fee.....................................................................................................add 50%

    # Z783 Secondary closure ................................................................................................... 97.35 7

    Note:Z783 is only eligible for payment for the delayed surgical closure of a wound. Debridement of a wound with healing by secondary intention is not payable as Z783.

    # R517 Excision of foreign body........................................................................................... 107.70 6# Z250 Chronic Electrical Stimulation (not to include T.E.N.S.) external or internal ............ 193.00 7# Z273 Muscle core biopsy using a 6mm or larger Bergstrom muscle biopsy needle or

    equivalent kit - includes one or more biopsies ................................................... 63.35

    Note:Z219 is not eligible for payment when rendered in addition to Z273.April 1, 2015 N3 Amd 12 Draft 1

  • MUSCULOSKELETAL SYSTEM SURGICAL PROCEDURESGENERAL FEES

    Asst Surg Anae

    ORTHOPAEDIC TUMOUR SURGERYR226 Biopsy of suspected sarco